Cognitive-Behavioral Therapy

The marriage of cognitive therapy and behavioral therapy has been a significant change in psychology. Even though both approaches first appeared to have very different methods; they both are scientific methods of altering thoughts and behaviors that interfere with someone's functioning and enjoyment of life. It is generally assumed there is a bi-directional causality between behavior and cognition; i.e., behavioral change leads to cognitive change, and cognitive change leads to behavioral change. Thus, nowadays few clinicians use a strictly behavioral approach, or a strictly cognitive approach, but instead employ a blend of both cognitive and behavioral techniques. For example, some therapy participants benefit from a few sessions of cognitive therapy before jumping into the more challenging, behavioral method of exposure and response prevention (ERP) exercises which can be somewhat uncomfortable. Decreasing certain dysfunctional beliefs assists the therapy participant to more readily tolerate the discomfort that can initially arise during ERP. Many studies have also found that the combination of these techniques, along with the appropriate medication, can produce the greatest treatment benefit for many of the anxiety disorders (Franklin & Foa, 2007).

As you have already learned, cognitive-behavioral therapy (CBT) evolved from sound theory and significant research data. In an attempt to standardize treatment, the American Psychological Association (APA) developed a task force whose goal was to compile lists of empirically supported treatments for psychiatric disorders. The APA encouraged the development of treatment protocol manuals to ensure that people would receive the best possible care through the use of standardized, efficacious treatment practices. The APA's task force had numerous requirements before a therapy could be approved as an empirically supported treatment. One such requirement was stringent, controlled, research studies consisting of standard scientific methods, such as random assignment to different treatment groups and/or wait-list control groups. Cognitive-behavioral techniques are consistently identified as the most effective type of treatment for anxiety disorders (Deacon & Abramowitz, 2004; Norton & Price, 2007; Stewart & Chamblass, 2009).

Hybrid Therapies

Overtime, the cognitive-behavioral model has been revised and modified, as well as integrated into other theories. This has resulted in the development of certain therapies that cannot be considered cognitive-behavioral therapies (CBT) in the strictest sense, but these therapies do rely heavily on the CBT foundation. Such therapies are sometimes referred to as hybrid therapies. There are two such therapies that have been successfully applied in the treatment of anxiety disorders: Acceptance and Commitment Therapy (ACT), and Dialectical Behavioral Therapy (DBT). Both of these therapies have modified the strong emphasis on change that is inherent in conventional CBT.

Acceptance and Commitment Therapy (ACT)

For those people who are reluctant to enter exposure and response prevention therapy, there is another approach that has recently attracted a lot of attention in the psychological literature, called Acceptance and Commitment Therapy (ACT). ACT is derived from functional contexualism and relational frame theory. While these concepts are highly abstract and quite complex, they can be distilled down to one essential feature: the recognition that words (and the thoughts formed with words) have an individual and unique meaning, which is dependent upon the person and the context in which the learning took place. The overall premise of ACT is the meaning and importance we assign to our thoughts, perpetuates our emotional suffering. While ACT is very similar to traditional cognitive-behavioral therapy (CBT), it differs in that it accepts and embraces dysfunctional thoughts. Instead of attempting to challenge and correct dysfunctional thoughts (as would conventional CBT), therapy participants are encouraged to view these thoughts dispassionately. So instead of attempting to challenge and correct the dysfunctional thought, "Everyone thinks I'm ugly," the person detaches from the meaning of their thought and instead considers, "I'm simply having a thought that everyone thinks I'm ugly." This places thoughts in their proper perspective: they are just thoughts, not facts, with no particular meaning other than the meaning we assign to them.

Because language allows us to attribute meaning to thoughts, it is possible for us to allow thoughts to enter our minds without giving them importance. ACT teaches people how to accept their emotional distress while simultaneously building a meaningful life that is anchored to their value system, rather than a life that is dictated by their symptoms. For example, in the case of Body Dysmorphic Disorder, therapy participants would be asked to examine the enormous value they place on their personal attractiveness, to the exclusion of other values which are important to them. Having identified other important values, therapy participants commit to actively pursuing a life that models these values. Therapy participants also learn to tolerate emotional pain through mindfulness training and meditation exercises, aimed at becoming aware of one's thoughts, feelings, images, and memories without judgment or avoidance. Incorporating ACT into cognitive-behavioral treatment for anxiety disorders may be a valuable tool to increase willingness to experience obsessions (Twohig, Hayes, & Masuda, 2006), and to target poor quality of life, high suicide rates, and depression, while reducing the immense suffering reported by people with anxiety disorders (Eifert, Forsyth, & Hayes, 2005).

Dialectical Behavior Therapy (DBT)

Dialectical behavior therapy (DBT) was initially developed by Marsha Linehan to treat highly suicidal, female patients diagnosed with Borderline Personality Disorder; a disorder characterized by emotional instability and interpersonal discord. Since the initial development of DBT in the early 1990's, its application has been broadened to include other populations and conditions. DBT is rooted in scientifically supported, cognitive-behavioral techniques but also integrates an Eastern philosophical approach of acceptance and mindfulness meditation. Dr. Linehan found that the heavy emphasis on change, inherent in cognitive-behavioral methods, was problematic for many therapy participants. For these people, this emphasis on change invalidated their experience and discounted their suffering.

The term "dialectic" refers to the synthesis of two opposing facts or ideas; thus in DBT, the dialectic is between change and acceptance. The goal of DBT is to help therapy participants find the balance between these two contradictory ideas. Other dialects are: work and play, emotions and reason, and fulfilling one's needs vs. fulfilling someone else's needs. DBT uses a combination of individual therapy along with structured, skills training groups INSERT LINK TO GROUPS p60. Participants are taught skills that enable them to: 1) better regulate their intense emotions, 2) become more effective in their interpersonal relationships, 3) improve their ability to cope with emotional crises, and 4) decrease their reliance on unhealthy coping behaviors such as substance abuse, self-injury, and suicidal behaviors.

Dialectical behavior therapy may be beneficial for persons who are reluctant to engage in exposure and response prevention therapy (ERP) INSERT LINK51 because they are unwilling, or unable to tolerate the inherent, but temporary, discomfort associated with ERP. Dialectical behavior therapy has helped people with PTSD INSERT LINKp34 to better tolerate exposure therapy (Becker & Zayfert, 2001). DBT may also be applied as an adjunct treatment for people with co-occurring disorders. For instance, DBT can be very helpful for people with anxiety disorders and Borderline Personality Disorder. Similarly, DBT is useful for people who have compulsive hair pulling (trichotillomania), nail biting, skin picking, or self injury; disorders which commonly co-occur with some of the anxiety disorders.

Authors Statement: Established in 1979, the Bio Behavioral Institute is a psychological and psychiatric clinic dedicated to the treatment and research of anxiety and mood disorders. Based in Long Island, NY, USA, the institute serves both a local and international clientele. Our staff have over 40 years of experience treating anxiety and mood disorders and have been at the forefront of scientifically supported treatments for anxiety disorders for many years. We offer a variety of programs provided by a multidisciplinary team of professionals. For more information, please visit us online at www.biobehavioralinstitute.com or view Bio Behavioral Institute and author biographical information on this website.